Failure to Administer Prescribed Controlled Medications Due to Staff Unawareness and Communication Breakdown
Penalty
Summary
The facility failed to ensure that residents with prescribed controlled medications, specifically Alprazolam, were administered their medications according to physician orders. Three residents with a history of Alprazolam use experienced multiple missed doses upon admission or during their stay. In each case, staff did not contact the physician when prescriptions were needed, and the medication was not administered as ordered. For example, one resident missed nine doses over several days, resulting in withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident missed three doses, and a third resident, a long-term facility resident, also missed three doses of Alprazolam. The investigation revealed that staff were unaware that Alprazolam was available in the facility's automated medication dispensing system. Multiple interviews with LPNs and the DON confirmed that nurses did not know they could access the medication from the dispensing system and did not notify the physician or document the missed doses as required. Progress notes for the affected residents did not include any documentation of the missed medication or physician notification. Staff interviews indicated a lack of training and awareness regarding the availability of controlled substances in the dispensing system and the proper procedures to follow when medications were unavailable. The facility's policy required that if a medication with a current, active order could not be located, staff should search all possible locations, contact the pharmacy, or remove the medication from the emergency kit. If a dose of a vital medication was withheld, refused, or not available, the physician was to be notified, and the notification documented. However, these procedures were not followed, and the lack of communication and documentation led to residents not receiving their prescribed medications, resulting in adverse symptoms for at least one resident.